6
Jaundice Macrophages: RBC -> Heme -> Unconjugated bili In the bloodstream: Unconj bili binds albumin (Indirect bilirubin) To the Liver: Uptake, then UDP glucoronyl transferase conjugates with glucuronic acid = Direct Bilirubin (now water soluble) From the hepatocytes to the gut in bile: Urobilinogen in the gut either is excreted in feces (80%, ‘stercobilin’) or reabsorbed (20%, most sent back to the liver, trace amount excreted in urine, ‘urobilin’)

22
A 52-year-old man comes to the emergency department because he has had vomiting, nausea, and abdominal pain for the past 12 hours. He says he attempted suicide 3 days ago by "taking everything in the medicine cabinet." He was stuporous for approximately 12 hours after the overdose but felt better the following day. At this time, he has jaundice and pain in the right upper quadrant. Which of the following drugs is most likely to have caused the pain, vomiting, and jaundice? (A) Acetaminophen (B) Aspirin (C) Cimetidine (D) Diphenhydramine (E) Triazolam

23
A 52-year-old man comes to the emergency department because he has had vomiting, nausea, and abdominal pain for the past 12 hours. He says he attempted suicide 3 days ago by "taking everything in the medicine cabinet." He was stuporous for approximately 12 hours after the overdose but felt better the following day. At this time, he has jaundice and pain in the right upper quadrant. Which of the following drugs is most likely to have caused the pain, vomiting, and jaundice? (A) Acetaminophen (B) Aspirin (C) Cimetidine (D) Diphenhydramine (E) Triazolam

26
A 25-year-old man comes to the physician because of progressive weakness and an increasingly protuberant abdomen during the past 3 years. Physical examination shows splenomegaly. His hematocrit is 28%, and platelet count is 20,000/mm3. A biopsy specimen of bone marrow shows accumulation of lipidladen macrophages. Glucocerebroside has accumulated in the patient's reticuloendothelial cells. Inheritance of mutant alleles most likely caused impairment of which of the following enzyme activities in this patient? (A) Ceramidase (B) α-Galactosidase (C) β-Glucosidase (D) Hexosaminidase (E) α-L-Iduronidase (F) Sphingomyelinase

27
A 25-year-old man comes to the physician because of progressive weakness and an increasingly protuberant abdomen during the past 3 years. Physical examination shows splenomegaly. His hematocrit is 28%, and platelet count is 20,000/mm3. A biopsy specimen of bone marrow shows accumulation of lipidladen macrophages. Glucocerebroside has accumulated in the patient's reticuloendothelial cells. Inheritance of mutant alleles most likely caused impairment of which of the following enzyme activities in this patient? (A) Ceramidase (B) α-Galactosidase (C) β-Glucosidase (D) Hexosaminidase (E) α-L-Iduronidase (F) Sphingomyelinase

28
A 6-week-old male infant is brought to the emergency department because of a swollen abdomen. He is refusing to eat and has not had a bowel movement for 3 days. His mother says that he had constipation since birth and was kept in the hospital an extra day after birth because of delayed passage of stool. Physical examination shows abdominal distention. An x-ray of the abdomen shows distended loops of proximal bowel with an abrupt narrowing to a small caliber of the distal 15-cm segment of colon. Which of the following pathologic findings is most likely in a biopsy specimen of the distal rectum in this patient? (A) Absent myenteric ganglion cells (B) Abundant inspissated mucus (C) Hypertrophy of the muscle wall (D) Nodular lymphoid hyperplasia (E) Transmural coagulative necrosis

29
A 6-week-old male infant is brought to the emergency department because of a swollen abdomen. He is refusing to eat and has not had a bowel movement for 3 days. His mother says that he had constipation since birth and was kept in the hospital an extra day after birth because of delayed passage of stool. Physical examination shows abdominal distention. An x-ray of the abdomen shows distended loops of proximal bowel with an abrupt narrowing to a small caliber of the distal 15-cm segment of colon. Which of the following pathologic findings is most likely in a biopsy specimen of the distal rectum in this patient? (A) Absent myenteric ganglion cells (B) Abundant inspissated mucus (C) Hypertrophy of the muscle wall (D) Nodular lymphoid hyperplasia (E) Transmural coagulative necrosis

30
An otherwise healthy 3-week-old boy is brought to the physician's office because of jaundice and dark urine for the past 2 weeks. He has hepatomegaly, and his stools are loose, claycolored, and acholic. Serum conjugated bilirubin concentration is increased. Which of the following is the most likely cause of the hyperbilirubinemia? (A) Defect in cholesterol synthesis (B) Deficiency of glucuronosyltransferase (C) Hemolysis (D) Inflammation of the terminal ileum (E) Obstruction of the biliary system

31
An otherwise healthy 3-week-old boy is brought to the physician's office because of jaundice and dark urine for the past 2 weeks. He has hepatomegaly, and his stools are loose, claycolored, and acholic. Serum conjugated bilirubin concentration is increased. Which of the following is the most likely cause of the hyperbilirubinemia? (A) Defect in cholesterol synthesis (B) Deficiency of glucuronosyltransferase (C) Hemolysis (D) Inflammation of the terminal ileum (E) Obstruction of the biliary system

32
A 4-year-old girl has the sudden onset of abdominal pain and vomiting. She has a mass inthe right lower quadrant and hyperactive bowel sounds. A segment of resected bowel is shown in the photograph. Which of the following is the most likely diagnosis? (A) Appendicitis (B) Intussusception (C) Meckel diverticulum (D) Necrotizing enterocolitis (E) Strangulated hernia

33
A 4-year-old girl has the sudden onset of abdominal pain and vomiting. She has a mass inthe right lower quadrant and hyperactive bowel sounds. A segment of resected bowel is shown in the photograph. Which of the following is the most likely diagnosis? (A) Appendicitis (B) Intussusception (C) Meckel diverticulum (D) Necrotizing enterocolitis (E) Strangulated hernia

34
A 76-year-old man comes to the emergency department because of a 12-hour history of fever and left lower quadrant abdominal pain. He has not passed a stool for the past 36 hours. His temperature is 38.3°C (100.9°F). A tender mass is palpable in the left lower quadrant of the abdomen. Stool is negative for occult blood. Laboratory studies show: Hemoglobin 13 g/dL Leukocyte count 17,000/mm3 (84% neutrophils) Platelet count 200,000/mm3 Serum amylase 115 U/L Urinalysis 0 to 1 WBC/hpf An x-ray of the abdomen shows no abnormalities. The most likely diagnosis is an acute episode of which of the following disorders? (A) Cystitis (B) Diverticulitis (C) Infectious colitis (D) Ischemic colitis (E) Pyelonephritis

35
A 76-year-old man comes to the emergency department because of a 12-hour history of fever and left lower quadrant abdominal pain. He has not passed a stool for the past 36 hours. His temperature is 38.3°C (100.9°F). A tender mass is palpable in the left lower quadrant of the abdomen. Stool is negative for occult blood. Laboratory studies show: Hemoglobin 13 g/dL Leukocyte count 17,000/mm3 (84% neutrophils) Platelet count 200,000/mm3 Serum amylase 115 U/L Urinalysis 0 to 1 WBC/hpf An x-ray of the abdomen shows no abnormalities. The most likely diagnosis is an acute episode of which of the following disorders? (A) Cystitis (B) Diverticulitis (C) Infectious colitis (D) Ischemic colitis (E) Pyelonephritis

36
A 5-year-old girl is brought to the emergency department because of fever and severe abdominal pain. Acute appendicitis is diagnosed. In the examination room, she keeps her right hip flexed and resists active extension of the hip. The inflamed structure associated with these symptoms is most likely in contact with which of the following structures? (A) Abdominal wall and the external oblique muscle (B) Obturator internus muscle (C) Psoas major muscle (D) Quadratus lumborum muscle (E) Transversus abdominis muscle

37
A 5-year-old girl is brought to the emergency department because of fever and severe abdominal pain. Acute appendicitis is diagnosed. In the examination room, she keeps her right hip flexed and resists active extension of the hip. The inflamed structure associated with these symptoms is most likely in contact with which of the following structures? (A) Abdominal wall and the external oblique muscle (B) Obturator internus muscle (C) Psoas major muscle (D) Quadratus lumborum muscle (E) Transversus abdominis muscle

38
A 55-year-old man who has alcoholic cirrhosis is brought to the emergency department because he has been vomiting blood for 2 hours. He has a 2- month history of abdominal distention, dilated veins over the anterior abdominal wall, and internal hemorrhoids. Which of the following veins is the most likely origin of the hematemesis? (A) Inferior mesenteric veins (B) Left gastric vein (C) Periumbilical veins (D) Superior rectal vein (E) Superior vena cava

39
A 55-year-old man who has alcoholic cirrhosis is brought to the emergency department because he has been vomiting blood for 2 hours. He has a 2- month history of abdominal distention, dilated veins over the anterior abdominal wall, and internal hemorrhoids. Which of the following veins is the most likely origin of the hematemesis? (A) Inferior mesenteric veins (B) Left gastric vein (C) Periumbilical veins (D) Superior rectal vein (E) Superior vena cava

40
A 30-year-old woman has anxiety about episodes of abdominal pain that have alternated with diarrhea and constipation over the past year. She often has these episodes when she is stressed or tired. Physical examination and laboratory studies are within normal limits during these episodes. Which of the following is the most likely diagnosis? (A) Gastroenteritis (B) Generalized anxiety disorder (C) Hypochondriasis (D) Irritable bowel syndrome (E) Major depressive disorder (F) Somatization disorder

41
A 30-year-old woman has anxiety about episodes of abdominal pain that have alternated with diarrhea and constipation over the past year. She often has these episodes when she is stressed or tired. Physical examination and laboratory studies are within normal limits during these episodes. Which of the following is the most likely diagnosis? (A) Gastroenteritis (B) Generalized anxiety disorder (C) Hypochondriasis (D) Irritable bowel syndrome (E) Major depressive disorder (F) Somatization disorder